Guidelines for CV Imaging in the ED Under Fire

SCAI, ASE upset with appropriate use criteria from other groups

New appropriate use criteria (AUC) for imaging patients with chest pain at the emergency room have serious flaws, according to the Society for Cardiovascular Angiography and Interventions (SCAI) and American Society of Echocardiography (ASE).

Their criticisms appeared in an editorial published in Catheterization and Cardiovascular Interventions, an "unusual step" taken because "the editor of the Journal of the American College of Cardiology [JACC] has declined to publish our concerns, stating that letters to the editor are instead referred to the AUC writing committee for consideration in the next version of the AUC document."

Blankenship and Wiegers took issue with the fact that SCAI and ASE were left out of the AUC Writing Panel, along with "any physician who routinely performs invasive angiography."

They also argued that the AUC suggests that "entirely guideline-based care is 'less than appropriate'" and invites payers to limit patient access to tests that are labeled "may be appropriate" (M) instead of "appropriate" (A).

Udelson, who was a member of the AUC writing committee, said he felt that the editorialists' contentions did not signal "dramatically contrasting advice really, as several things may be appropriate at once depending on the scenario."

Blankenship and Wiegers also criticized the M* rating, a category not previously seen in AUC documents. Intended to designate that the panel could not reach consensus on a rating, the prevalence of M* ratings (used 23 times in the current AUC) signal a "failure to resolve lack of consensus within a small rating panel," Blankenship and Wiegers wrote.

Udelson defended the M* rating, however, emphasizing that it was a way to denote clinician disagreement with full transparency. "We thought it would be important for people to know that even a group of heterogeneous clinicians felt the literature wasn't strong enough to drive everyone to a particular rating," he noted.

He also maintained that the existing AUC wouldn't be edited anytime soon. "The ratings are done and we can't change them," he said.

Blankenship, Wiegers, and Udelson reported no relevant conflicts of interest.

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